NURSING 309 Focus on Mental Health Questions and Answers 2020

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D: 9476853992
A nurse overhears a hospitalized client with mania telling another client, “I’m actually a journalist writing an article for a magazine — I’m just posing as a person with me... ntal illness.” How should the nurse respond? A. Ignoring the delusion B. Taking the client to a quiet room C. Supporting the client’s denial of illness D. Presenting the client with the actual situation Correct
Rationale: When dealing with a delusional client, it is important for the nurse to state clearly that the nurse does not share the client’s perceptions. All three of the other options — ignoring the delusion, taking the client to a quiet room, and supporting the client’s denial of illness — do not focus on reality, and they ignore the issue. Presenting the client with the actual situation helps orient the client to reality.
Test-Taking Strategy: Use the process of elimination and your knowledge that reality orientation is the priority. The correct option illustrates a means of helping orient the client to reality. Review care of the client experiencing delusions if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition – Psychosis, Stress and Coping – Caregiving
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 305, 318-320). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
2.ID: 9476861052
A client who is hallucinating fearfully says to the nurse, “Please tell that demon to get out.” How should the nurse respond to the client? A. “If you tell the demon to go away, it will.” B. “I’ll stay here with you until the demon leaves your room.” C. “If you return to bed, you will find that the demon will leave.” D. “I know you must be very upset by this, but I don’t see a demon.” Correct
Rationale: If the client hallucinates, it is best to provide reality-based perceptions and not negate the client’s experience, because this may lead to a regressive struggle with the client. Giving advice or false reassurance is incorrect because such techniques indicate that demons actually are present, which feeds into the client’s hallucination and reinforces the client’s behavior.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques, noting that the client is hallucinating. Remember that it is most important to maintain reality with the client. This will direct you to the correct option. Review communication techniques for the client who is hallucinating if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Psychosis
HESI Concepts: Cognition – Psychosis, Communication
References: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 25-29). St. Louis: Mosby.
Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. p. 320). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 9476835369
The mother of a 3-year-old says, “My child hit his teddy bear after being scolded for picking the neighbors’ flowers.” Which defense mechanism was the child using? A. Projection B. Sublimation C. Displacement Correct D. Identification
Rationale: The defense mechanism of displacement involves the discharge of intense feelings for one person onto a less threatening substitute person or object to satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse to someone else, such as that which occurs in blaming or scapegoating. Sublimation is rechanneling an impulse into a more socially acceptable object. Identification involves modeling behavior after someone else's.
Test-Taking Strategy: Use the process of elimination and your knowledge regarding defense mechanisms. Focusing on the child’s behavior will direct you to the correct option. Review these defense mechanisms if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Mental Health
Giddens Concepts: Development, Coping
HESI Concepts: Developmental, Stress and Coping
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 171, 173). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
4.ID: 9476840153
A client says to the nurse, “Even though my husband and I keep telling them we don’t want to have children, our parents are pressuring us to ‘start a family.’ What should we say to them?” Which of the following responses by the nurse is therapeutic? A. “This must be very difficult for both of you.” Correct B. “Maybe you should say you can’t have children.” C. “How do you usually cope with that kind of interference?” D. “Tell them to have more children if they want them so badly.”
Rationale: Childless families may elect not to have children or to postpone having them until they have established themselves occupationally or financially. Telling the client to tell the parents that the couple can’t have children is incorrect because the client is being encouraged to lie about life decisions rather than helping the parents understand the couple’s choices. Asking how they usually cope with such interference is incorrect because it indicates that the nurse is judgmental and has decided that the parents are interfering with the client and spouse. Saying, “Tell them to have more children if they want them so badly,” is incorrect because it is sarcastic and ridicules the situation over which the client has expressed concerns.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Family Dynamics
HESI Concepts: Communication, Family Dynamics
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 27). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
5.ID: 9476840163
A young adult client says, “I just can’t seem to stop snapping at my parents. I know they work hard to support me, but what do I do when they’re so overbearing?” Which responses by the nurse is therapeutic? A. “It’s important not to be rude to your parents.” B. “You need to be more patient with your parents.” C. “Snapping at your parents is childish. How could you?” D. “Have you talked to your parents about your frustrations?” E. Correct
Rationale: The correct response is focused on the client’s concerns and encourages the therapeutic technique of formulating a plan of action. “It’s important not to be rude to your parents” and “You need to be more patient with your parents” are both nontherapeutic, judgmental responses that do not encourage the client to further explore her feelings and problem-solve. “Snapping at your parents is childish. How could you?” is incorrect because it is sarcastic and condescending, which is nontherapeutic.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Family Dynamics
HESI Concepts: Communication, Family Dynamics
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 29, 31). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
6.ID: 9476853973
A client says, “I have so much trouble caring for my husband’s child from his first marriage. I resent the money we have to pay for child support because we have to deprive my own child of things. How can I stop feeling this way?” Which response by the nurse is therapeutic? A. “Your child benefits from having a sibling.” B. “Have you shared your feelings with your husband?” Correct C. “You need to take a second job to give your child what you think she deserves.” D. “I wonder why you married him, knowing that he wouldn’t desert his biological child.”
Rationale: Remarried individuals often encounter problems as a result of the stressors they bring into a marriage without prior discussion with the new partner. Bonding sometimes does always occur when a child is not one’s biological offspring. The correct answer is focused on the client’s feelings. “Your child benefits from having a sibling” is not facilitative. “I wonder why you married him, knowing that he wouldn’t desert his biological child” is incorrect because it prejudges the client. “You need to take a second job to give your child what you think she deserves” is not open ended, does not facilitate feelings, and gives advice.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Family Dynamics
HESI Concepts: Communication, Family Dynamics
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 27). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
7.ID: 9476861090
A client says to the nurse, “My wife retired last year from a lucrative law practice, and I’m really discouraged. I’ll be working until I die, even though I helped pay for her education.” Which response by the nurse is supportive? A. “That’s very unfair to you.” B. “You sound very troubled by this.” Correct C. “That’s such a tough break for you.” D. “Why not ask your wife for some help?”
Rationale: Saying that the situation is unfair is judgmental and does not encourage the client to express his feelings; nor does “That’s such a tough break for you.” Suggesting that the husband approach the spouse for help is incorrect because it prematurely gives advice, a nontherapeutic communication technique. The correct option is focused on the client’s feelings.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Family Dynamics
HESI Concepts: Communication, Family Dynamics
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 124-125). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
8.ID: 9476861043
A gay man is brought to the emergency department by the police. The client tells the nurse, “I was beaten up. I guess I just have to expect this kind of treatment for the rest of my life.” Which statement by the nurse is therapeutic? A. “I think you should take some self-defense classes.” B. “Maybe you should be more discreet when you’re in public.” C. “You feel that being beaten up goes along with being gay?” Correct D. “Why not try counseling to change your sexual orientation?”
Rationale: Many lesbians and gays encounter harassment or violence in the course of their lives. “I think you should take some self-defense classes” is incorrect because it advises the client, and giving advice is not therapeutic. “Maybe you should be more discreet when you’re in public” also gives advice and presumes that the client has been indiscreet. “Why not try counseling to change your sexual orientation?” is incorrect because it assumes that sexual orientation can or should be changed. The correct option indicates reflection and is focused on the client’s feelings.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques and remember to focus on the client’s feelings. This will direct you to the correct option. Review these techniques if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Giddens Concepts: Communication, Interpersonal Violence
HESI Concepts: Communication, Violence
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., p. 515). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
9.ID: 9476853957
A client whose spouse recently died is experiencing dysfunctional grieving. Which intervention has priority in the plan of care? A. Monitoring the client’s sleep pattern B. Assessing the client’s risk for violence toward self and others Correct C. Collaborating with the healthcare provider to prescribe an antidepressant D. Helping the client resolve the grief through emotional, cognitive, and behavioral means
Rationale: The priority intervention for a client with dysfunctional grieving is assessment of the client’s risk for violence toward self and others. Although the nurse will assist the client in resolving the grief and monitor the client’s sleep pattern, these are not the priority interventions of the options given. Obtaining a prescription for an antidepressant is not a priority.
Test-Taking Strategy: Use the process of elimination and the steps of the nursing process. Assessing the client’s risk for violence toward self and others and monitoring the client’s sleep pattern are both forms of assessment. To select from the remaining options, select assessing the client’s risk for violence toward self and others because it addresses the safety of the client. Review interventions for a client experiencing dysfunctional grieving if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Mental Health

Giddens Concepts: Coping, Interpersonal Violence
HESI Concepts: Grief and Loss, Violence
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 488-489). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
10.ID: 9476848561
A nurse develops a plan of care for a client in whom AIDS was recently diagnosed. The client is experiencing difficulty adjusting to the illness. Which interventions are appropriate for this client? Select all that apply. A. Assisting the client in verbalizing fears Correct B. Helping the client identify sources of hope Correct C. Monitoring the client for signs of self-harm Correct D. Assisting the client with problem-solving and decision-making Correct E. Discouraging social networking to prevent the spread of infection
Rationale: Assisting the client with problem-solving and decision-making, helping the client verbalize fears, helping the client identify sources of hope, and monitoring the client for signs of self-harm are all appropriate interventions. In planning care for a client having difficulty adjusting to an illness, the nurse develops interventions to promote social networking that will provide needed support and information to the client.
Test-Taking Strategy: Use the process of elimination and note that the client is having difficulty adjusting to a serious illness. Recall that social support is important. Review interventions for a client having difficulty adjusting to an illness if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Mental Health
Giddens Concepts: Anxiety, Coping
HESI Concepts: Mood and Affect – Anxiety, Stress and Coping
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 235-236 ). St. Louis: Mosby.
Awarded 4.0 points out of 4.0 possible points.
11.ID: 9476855957
An emergency department nurse is caring for an older client who is a victim of physical abuse. List in order of priority the following nursing actions, with number 1 representing the first action and number 4 the last.
Correct A. Checking the client for physical injuries B. Contacting the appropriate state officials to report the abuse C. Contacting a social worker to assist in planning care for the client D. Calling a member of the clergy to address the client’s spiritual needs
Rationale: The priority intervention in the event of physical abuse is to check the client for physical injuries. The nurse should then fulfill the legal obligation of reporting suspected elder abuse. The next action is to contact the social worker to obtain assistance in planning care for the client. The client may need the social worker’s help with housing as well. Last, a referral to a member of the clergy is an appropriate intervention if the client desires it.
Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Remember, physiological needs are the priority. Recall that legal reporting is necessary and should be performed next. To prioritize the remaining options, select the one that involves safety and security as the third action. Review care of the abused elderly client if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Giddens Concepts: Cargiving, Interpersonal Violence
HESI Concepts: Stress and Coping – Caregiving, Violence
Reference: Varcarolis, E. (2013). Essentials of Psychiatric Mental Health Nursing: A communication approach to evidence-based care. (revised reprint)) (2nd ed. pp. 427-428). St. Louis: Saunders.
Awarded 1.0 points out of 1.0 possible points.
12.ID: 9476855949
The parents of an 18-month-old arrive at the emergency department with their unconscious child. Physical examination reveals bruises on the child’s upper arms that resemble grip marks. Which nursing intervention is the priority? A. Stabilizing the child’s physical condition Correct B. Securing a safe environment for the child C. Confronting the parents with regard to suspected abuse D. Contacting the appropriate state officials to report the suspected abuse
Rationale: In all child abuse cases, the primary concern is the physical condition of the child. Although contacting appropriate state officials to report suspected abuse and securing a safe environment for the child are both interventions that need to be performed, this child is unconscious, so the priority is to stabilize the child’s physical condition. Confronting the parents about the abuse at this time may cause resentment and conflict in the parents, and the parents might attempt to leave the emergency department with their child.
Test-Taking Strategy: Note the strategic word “priority.” Use Maslow’s Hierarchy of Needs theory to answer this question. Recalling that physiological needs are the priority will direct you to the correct option. Review care of the child who has been physically abused if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Mental Health
Giddens Concepts: Clinical Judgment, Interpersonal Violence
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Violence
Reference: Dolan, B. & Holt, L. (2013). Accident & Emergency Theory into Practice (3rd ed., pp. 262-263). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
13.ID: 9476844034
A nurse in a women’s clinic develops a plan of care for abused women. Which tertiary prevention intervention should be included in the plan of care? A. Identifying families at risk for abuse B. Early case-finding and decisive intervention C. Changing societal views toward domestic abuse D. Assisting abused women in overcoming the physical and psychological effects of abuse Correct
Rationale: Primary prevention intervention (here, identifying families at risk for abuse and changing societal views toward domestic abuse) is focused on risk identification and health promotion and prevention of disorders. Secondary prevention interventions (early case-finding and decisive intervention) are focused on early identification and treatment of a problem. Tertiary prevention intervention (helping abused women overcome the physical and psychological effects of abuse) is focused on reducing the residual effects of a disorder and rehabilitation.
Test-Taking Strategy: Uses the process of elimination, focusing on the subject, a tertiary prevention intervention. Recalling the definitions of each prevention level will direct you to the correct option. Review these definitions if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Mental Health
Giddens Concepts: Cargiving, Interpersonal Violence
HESI Concepts: Stress and Coping – Caregiving, Violence
Reference: Stuart, G. (2013). Principles & practice of psychiatric nursing (10th ed., pp. 739-740). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
14.ID: 9476847258
A nurse assists in caring for victims of an explosion at a local industrial plant. The nurse plans to implement crisis interventions, knowing that this incident is characteristic of: A. A situational crisis B. An individual crisis C. A maturational crisis D. An adventitious crisis Correct [Show More]

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